A pancreatic pseudocyst is a maturing collection of pancreatic juice encased tissue and develops either inside or around the pancreas. Pseudocysts occur most commonly after an episode of pancreatitis or abdominal trauma. Pseudocysts can be single or multiple, small or large. Depending on the nature of the cyst (size, location, or cause), some will improve on their own, while others require treatment.

How are they treated?

At NewYork-Presbyterian/Weill Cornell, we have a team that specializes in the management of these pseudocysts and fluid collections which includes gastroenterologists, radiologists, interventional radiologists, and surgeons. We evaluate each patient individually. In some cases, conservative management is appropriate. For instance, if a patient's pseudocyst is small and is not causing any symptoms, sometime just monitoring the patient is appropriate. In these patients, we address nutritional issues, make sure the pseudocyst resolves, and prevent complications. In addition, it is important to determine the cause of the disorder in order to avoid another episode.

In other patients, however, drainage of the pseudocyst is needed. Drainage is more commonly required in patients with pseudocysts or necrosis (dead tissue) causing symptoms (such as abdominal pain, nausea, vomiting, and difficulty eating) or if complications such as infection or bleeding occur.

When drainage is required, we have a highly specialized team that can determine which method of drainage is best for each patient. We have experts in surgery, interventional radiology, and gastroenterology who are able to provide drainage with the most up-to-date methods.

In the past, most patients who required treatment for these pseudocysts had to have surgery, but we are now able to drain many of these collections with less invasive endoscopic procedures.Examples include:

Echoendoscopy: A stent is used to drain the pseudocyst by connecting it to an adjacent intestinal organ, using an endoscope with an ultrasound transducer at the tip.

Cystogastrostomy: A connection is created between the back wall of the stomach and the cyst to drain it directly into the stomach.

Cystojejunostomy: A connection is created between the cyst and the small intestine so that the cyst fluid can drain directly into the small intestine.

Cystoduodenostomy: A connection is created between the duodenum and the cyst to allow drainage of the cyst fluid directly into duodenum.

The type of drainage depends on the location of the cyst. For pseudocysts that occur in the body and tail of the pancreas, a cystogastrostomy is performed. For pseudocysts that occur in the head of the pancreas, a cystoduodenostomy is preferred.

Our team plans to introduce a new pseudocyst drainage stent and delivery system through a clinical trial. This system promises to be safer and more efficient than other stents.

What are pancreatic cysts, and why are they increasing in incidence?

Pancreatic cysts are being diagnosed more and more frequently due to the wide use of cross-sectional imaging techniques, such as CT scans and MRI. These cysts may be diagnosed due to symptoms they are causing, or as incidental findings on imaging tests obtained for another reason. There are many different types of pancreatic cysts, and they vary widely in their potential to become cancerous.

Accurate cyst classification is important to help determine which cysts have malignant potential and require surgery, and which cysts are less of a concern and can be monitored or may not even require follow-up.

How are pancreatic cysts diagnosed and classified?

Tools that we use to help classify and follow pancreatic cysts include state-of-the-art CT and MRI scans which include protocols with specific attention to the pancreas. We also specialize in performing endoscopic ultrasound (EUS), which allows us to obtain detailed visualization and important predictive data regarding these cysts.

Endoscopic ultrasound may be used to evaluate pancreatic pseudocysts

EUS also allows us to obtain samples of the cyst, which is then analyzed to help classify the cyst further. When needed, we can also use a special type of endoscopy to help us directly visualize the pancreatic duct. This procedure is referred to as "endoscopic retrograde cholangiopancreotography (ERCP)."

In addition to routine ERCP, we can perform pancreatoscopy (direct visualization of the pancreatic duct) and take targeted samples or tissue biopsies. We are also one of the few centers in the country that performs confocal imaging of the pancreatic duct and pancreatic cysts.

We plan to participate in a multicenter confocal imaging clinical trial that would allow us to evaluate whether confocal imaging affects clinical management and, in turn, improves patients' quality of life.

Balloon dilation was used to access this pseudocyst

What treatments are available?

For patients who require surgery, we have pancreatic surgeons on our team who specialize in the treatment of pancreatic cysts. In addition to the standard options of surgery and surveillance, we are also able to provide ablative management of these cysts through the injection of alcohol into the cyst cavity.

How can I make an appointment to see an advanced endoscopist?

Our specialists are experienced in diagnosing and treating pancreatic cysts and pseudocysts. An interdisciplinary team of gastrointestinal specialists in endoscopy, radiology, and surgery work together as a team to provide each patient with coordinated, advanced, and individualized care. Please contact our Advanced Interventional Endoscopy team to discuss your case.